PAPER III: SUBJECT SPECIALISATION PAPER FOR PHARMACY

ROYAL CIVIL SERVICE COMMISSION

BHUTAN CIVIL SERVICE EXAMINATION (BCSE) 2023
EXAMINATION CATEGORY: TECHNICAL

PAPER III: SUBJECT SPECIALISATION PAPER FOR PHARMACY

Date : October 7, 2023

Total Marks : 100
Writing Time : 150 minutes (2.5 hours)
Reading Time : 15 Minutes (prior to writing time)

GENERAL INSTRUCTIONS:
1. Write your Registration Number clearly and correctly on the Answer Booklet.
2. The first 15 minutes is to check the number of pages of Question Paper, printing errors, clarify
doubts and to read the instructions. You are not permitted to write during this time.
3. This paper consists of TWO SECTIONS, namely SECTION A & SECTION B:
• SECTION A has two parts: Part I - 30 Multiple Choice Questions
Part II - 4 Short Answer Questions
All questions under SECTION A are COMPULSORY.
• SECTION B consists of two Case Studies. Choose only ONE case study and answer the
question of your choice.
4. All answers should be written on the Answer Booklet provided to you. Candidates are not
allowed to write anything on the question paper. If required, ask for additional Answer Booklet.
5. All answers should be written with correct numbering of Section, Part and Question Number in
the Answer Booklet provided to you. Note that any answer written without indicating the correct
Section, Part and Question Number will NOT be evaluated and no marks will be awarded.
6. Begin each Section and Part in a fresh page of the Answer Booklet.
7. You are not permitted to tear off any sheet(s) of the Answer Booklet as well as the Question
Paper.
8. Use of any other paper including paper for rough work is not permitted.
9. You must hand over the Answer Booklet to the Invigilator before leaving the examination
hall.
10. This paper has 8 printed pages, including this instruction page.

GOOD LUCK

Page 1 of 8
 PAPER III: SUBJECT SPECIALISATION PAPER FOR PHARMACY

SECTION A
PART I: Multiple Choice Questions [30 marks]
Choose the correct answer and write down the letter of your chosen answer in the Answer
booklet against the question number e.g. 31 (d). Each question carries ONE mark. Any double
writing, smudgy answers or writing more than one choice shall not be evaluated.
1. Select an antibiotic which possess activity against an anerobic pathogen from the following.
a) Phenoxymethylpenicillin
b) Trimethoprim + sulfamethoxazole
c) Metronidazole
d) Ceftriaxone
2. According to the US-FDA (Food Drug Authority), the pregnancy category of losartan is
a) A
b) B
c) C
d) D

3. Which of the following vitamin is considered water insoluble vitamin?

a) Vitamin C
b) Vitamin B complex
c) Vitamin E
d) All of the above
4. Which of the following is considered as the universal antidote?
a) Atropine
b) N-acetylcysteine
c) Flumazenil
d) Activated charcoal

5. Identify the SSRI (selective serotonin reuptake inhibitor) from the following list
a) Venlafaxtine
b) Fluoxetine
c) Lithium
d) Imipramine

6. Which of the following anti-parkinson agent is recommended to be used for the treatment of
hyperprolactinemia?
a) Levodopa
b) Selegeline
c) Bromocriptine
d) Amantadine

7. Clonidine is ____________, which causes reduction in HR, BP and renal vascular resistance.
a) Alpha 1 agonist
b) Alpha 2 agonist
c) Alpha 1 antagonist
d) Alpha 2 antagonist

Page 2 of 8
 PAPER III: SUBJECT SPECIALISATION PAPER FOR PHARMACY

8. Which of the following adverse effect of chlorpromazine and phenothiazine is explained by their
dopaminergic action?
a) Extrapyramidal syndrome
b) Dry mouth
c) Constipation
d) Eruptions

9. Adding adrenaline to lidocaine solution for a subcutaneous administration can prolong the duration
of local anesthesia by
a) causing precipitation of lidocaine.
b) decreasing permeability of the vascular epithelium.
c) inducing local vasoconstriction.
d) changing the pH of the solution.

10. _________________is an agent used in preventing the withdrawal symptoms and reducing the
cravings without inducing euphoria and sleep.
a) Chlorpromazine
b) Haloperidol
c) Diazepam
d) Buprenorphine

11. Which group of antibiotics has the nephrotoxic property in normal renal function?
a) Aminoglycoside
b) Beta-lactams
c) Macrolides
d) Quinolones

12. A diuretic agent which inhibits carbonic anhydrase enzyme in the proximal tubular epithelial cell:
a) Furosemide
b) Amiloride
c) Acetazolamide
d) Hydrochlorothiazide

13. Which antibiotic results in the formation of crystalluria?

a) Ceftriaxone
b) Sulfamethoxazole
c) Metronidazole
d) Nitrofurantoin

14. Among the following ARV (anti-retroviral) agents, select an agent which induces renal
impairment.
a) Tenofovir
b) Efavirenz
c) Dolutegravir
d) Zidovudine

Page 3 of 8
 PAPER III: SUBJECT SPECIALISATION PAPER FOR PHARMACY

15. Identify an agent which doesn’t belong to the category of mucosal protective agents.
a) Bismuth subsalicylate
b) Sucralfate
c) Misoprostol
d) Domperidone
16. Indicate the peripheral dopa decarboxylase inhibitor from the following.
a) Carbidopa
b) Entacapone
c) Selegeline
d) Clozapine
17. A 19-year-old male presents to ER (emergency room) with a bacterial meningitis. Which of the
following cephalosporin is recommended to be initiated in this patient?
a) Cefuroxime
b) Cephalexin
c) Ceftriaxone
d) Cefotaxime
18. Indicate an agent recommended to be used in the treatment of ADHD (attention deficit
hyperactivity disorder).
a) Olanzapine
b) Clozapine
c) Amitriptyline
d) Methylphenidate
19. Which of the following statement is INCORRECT concerning the Sod. Valproate?
a) Recommended in all forms of seizure
b) Causes thrombocytopenia and hepatotoxicity
c) Recommended as a prophylaxis and treatment in manic episodes in patient with bipolar
disorder unresponsive to lithium
d) Considered safe during pregnancy
20. Which antibacterial agent causes “Red man syndrome” if infused rapidly?
a) Piperacillin
b) Vancomycin
c) Clindamycin
d) Amikacin
21. Local adverse effect of inhaled corticosteroids is
a) Maculopapular rash
b) Cellulitis
c) Oral candidiasis
d) SJS (Steven Johnson syndrome)
22. Which of the following anti-flatulent agent is added in antacid?
a) Simethicone
b) Sucralfate
c) Misoprostol
d) Alginic acid

Page 4 of 8
 PAPER III: SUBJECT SPECIALISATION PAPER FOR PHARMACY

23. The most preferred treatment option in infants with the mild diaper dermatitis is
a) Acyclovir ointment
b) Zinc oxide paste
c) Clotrimazole ointment
d) Nystatin paste

24. Alcohol is recommended to be completely avoided while taking metronidazole due to serious
adverse effect known as
a) Serotonergic syndrome
b) Hypertension crisis
c) Disulfiram like reaction
d) Severe hypernatremia

25. A patient diagnosed with TB and treated with the oral isoniazid developed muscles aches,
paresthesia and unsteadiness. Indicate the vitamin recommended to reverse these symptoms.
a) Vitamin A
b) Vitamin B1
c) Vitamin B6
d) Vitamin K

26. A patient advised to take amoxycillin, clarithromycin and pantoprazole. What is the most likely
condition considering the combination?
a) Antibiotic associated colitis
b) IBS (irritable bowel syndrome)
c) NSAIDs induced gastritis
d) H. pylori induced gastritis

27. Identify the CORRECT mechanism of action of Ondansetron.

a) 5-HT3 receptor blocker
b) Dopamine receptor blocker
c) H2 receptor blocker
d) Muscarinic receptor blocker

28. Which of the following is a proper dietary counseling for patients being treated with the warfarin?
a) Avoid all foods containing vitamin K
b) Avoid excessive alcohol intake as it decreases the effectiveness of warfarin
c) Maintain consistent dietary vitamin K intake
d) Maintain current dietary intake because vitamins and supplements interact with warfarin

29. Methadone is considered in the treatment programs of narcotic addiction. What is the category of
this medicine?
a) Psychotropic agent
b) Opioid analgesic
c) NSAIDs
d) Benzodiazepines

Page 5 of 8
 PAPER III: SUBJECT SPECIALISATION PAPER FOR PHARMACY

30. A 30-year-old man is brought to ER (emergency room) after ingesting a large but unknown
quantity of acetaminophen. The use of NAC (N-acetylcysteine) is considered in this patient based
on the goal of
a) Inhibiting drug absorption
b) Increasing drug elimination
c) Decreasing target receptor binding
d) Inactivating a toxic metabolite

PART II – Short Answer Questions [20 marks]

This part has FOUR Short Questions carrying 5 marks each. Answer ALL the questions.
1. Explain the mechanism involved in food-drug interaction at the metabolism level. Give one
example.
2. Explain three types of mechanism with examples how bacteria develop resistance against the
antibiotics.
3. Enlist five objectives of NEML (National Essential Medicines List).
4. Describe any three methods used in the quality testing of tablets.

SECTION B: Case Study [50 marks]

Choose either CASE I OR CASE II from this section. Each case carries 50 marks. Mark for each
sub-question is indicated in the brackets.
CASE I
A 54-year-old woman previously diagnosed with the T2DM (Type-2 Diabetes Mellitus) returns to the
diabetic clinic for her scheduled follow up with a chronically elevated blood glucose. At her last visit 3
months ago, her HbA1C was 7.6%, where it had been for several visits. She was recommended to
begin treatment with insulin. She was advised to administer insulin soluble 0.4 units/kg/day SC
divided q8hr. She was then advised to increase her dose of oral glipizide from 5 mg to 10 mg once a
day and advised her to more strictly follow her diet and exercise regimen, which she claims to be
doing. Since the last visit, her home fingerstick glucose levels have ranged from 119 mg/dL to 263
mg/dL (6.6 to 14.6 mmol/L) and her weight on her home scale is unchanged at about 98 kg. She
describes increased thirst and urination but denies blurry vision, nonhealing ulcers, or lethargy.
At the diabetic clinic, a fingerstick glucose test on arrival today shows glucose level of 221mg/dL
(12.27 mmol/L) and hemoglobin A1C 8.1%; urine dipstick is normal.
• General: Increased thirst and is drinking more water. Appetite is normal and her weight at home
has been unchanged for several months. She denies lethargy, fever, chills, or night sweats.
• Skin: No rash, pruritus, or lesions
• Pulmonary: No cough, shortness of breath, wheezing
• Cardiovascular: No chest pain, pressure, or discomfort; no orthopnea, dyspnea on exertion, or
paroxysmal nocturnal dyspnea.
• Gastrointestinal: No abdominal pain, nausea, vomiting, diarrhea
• Genitourinary: Increased urinary frequency without urgency, dysuria, or blood in urine. No
vaginal discharge or itching.
• Musculoskeletal: No joint or muscle pain, no sores or lesions on feet.
• Neurologic: Has numbness and tingling in both feet that comes and goes throughout the day. No
headache, tremor, change in gait.
Page 6 of 8
 PAPER III: SUBJECT SPECIALISATION PAPER FOR PHARMACY

• Psychiatric: No mood swings, depression, or anxiety.

• Medical history: Hypertension, type 2 diabetes mellitus, hyperlipidemia, and obesity
• Surgical history: Cholecystectomy 5 years prior
• Medications: Metformin 1000 mgpoq12hourly, atorvastatin 80 mgpoq24hourly, glipizide
5mgpoq24hourly, Enalapril 10 mgpoq24 hourly, Aspirin 75mg poq24 hourly, Clopidogrel 75mg
poq24hourly, all of which she claims to be adhering 100%.
• Allergies: Penicillin, which causes maculopapular rash.
• Family history: Father died from myocardial infarction at age 89 years, mother age 88 years has
type 2 diabetes mellitus, hypertension, and hyperlipidemia.
• Social history: Patient works as a social worker, has never smoked cigarettes, denies any illicit
drug use, drinks 1 to 2 glasses of wine with dinner every night. She rides a stationary bike about 1
to 2 days per week for 20 minutes, which she has been able to do without difficulty.
• Vital signs:
• Temperature: 37° C
• Pulse: 82 min
• BP: 159/88 mmHg
• Respirations: 12/min
• Skin: There is velvety smooth hyperpigmentation in neck folds and under arms; no other lesions
or rash.
• Cardiovascular: Regular rate and rhythm; no murmurs, gallops, or rubs. Jugular venous
distention normal.
• Gastrointestinal: Obese abdomen, soft, non-distended, normal bowel sounds, no rebound or
guarding
• Genitourinary: No signs of yeast infection or other lesions. No tenderness to flank percussion.
• Musculoskeletal: No peripheral edema, swelling or tenderness. Joints full range of motion and
nontender.
• Neurologic: Decreased sensation to light touch in feet bilaterally. Cranial nerves II to VIII grossly
intact, normal gait, strength 5/5 throughout.
• Mental status: Alert and oriented x3

Answer the following questions based on the above information.

1. The above patient claimed that her adherence is 100%. Do you agree or disagree and why? (2)
2. Explain the mechanism of action of insulin (3).
3. Provide the following patient education/counselling on the use of insulin soluble;
a) Storage condition (2)
b) Administration time with respect to meal and why (2 + 2)
c) Two common side effects of insulin (2)
4. Enlist three microvascular complications related to diabetes mellitus (3)
5. From the patient’s medication history, explain the pharmacology (mechanism of action, maximum
daily dose and common side effects) of atorvastatin. Also mention the specific timing of
atorvastatin and why? (5 + 4).
6. Explain the pharmacologic role of omeprazole in the patient (2).
7. Carefully review the medication list of the patient and identify one serious drug – drug interaction
and explain the mechanism involved (2 + 4).
8. In the above patient, explain the pharmacologic role of Aspirin (2).

Page 7 of 8
 PAPER III: SUBJECT SPECIALISATION PAPER FOR PHARMACY

9. Explain two reliable methods used to assess adherence to chronic medicines other than asking the
patients directly (6).
10. As a pharmacist, provide a detailed patient education and counseling (medication timing, common
adverse side effects) on the use of following medicines (3 + 3).
a) Metformin
b) Glipizide
11. As per the patient’s medical history, the patient is allergic to penicillin antibiotic. Explain the
cross-reactivity of penicillin group of antibiotics (3).

CASE II
Mr. XXX is the Head, Department of Pharmacy, JDWNRH since 2017. As a head of the department,
he is focused on the following activities to enhance the efficiency of pharmaceutical care services in
the country.
• Developing the national essential medicines list in the country
• Rational use of antibiotics
• Standardization of prescription in the country
• Standardization of error prone abbreviation of medicines
• DIS (Drug information services)
• DUE (Drug use evaluation)
• TDM (Therapeutic drug monitoring)
• Stock management
Answer the following questions;
1. Explain how you can enhance the optimum utilization of NEML (national essential medicine list)
among the prescribers and pharmacist (4).
2. Draw your own flowchart/process how to ensure rational use of antibiotics in the hospital and
explain how it can prevent the emergence of antibiotic resistance in the country (8)
3. Explain the importance of standardization of prescription in the country (4)
4. Enlist some of the error prone abbreviations encountered across the hospitals (4)
5. Currently, the hospitals in Bhutan failed to establish a standard DIS to assist prescribers and
patients. Explain your ideas with a clear and detailed flow-chart on how to establish a complete
DIS in the hospital (8).
6. Enlist the category of medicines which are generally recommended to be evaluated on its use. Also
explain the impact or positive outcomes of DUE for the country (3 + 3).
7. Explain the therapeutic index, toxicity and sub-therapeutic level of a drug with a graphical
representation (6).
8. Enlist six medicines which are recommended to undergo therapeutic drug monitoring and explain
why (3 + 2).
9. Draw your own flow-chart (i.e., standard operating procedure) on how to ensure effective and
efficient stock management system in the hospital (5)

TASHI DELEK

Page 8 of 8